ASH Scotland Tobacco Use, Ethnicity and Health June 2014
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ASH Scotland Tobacco use, ethnicity and health June 2014 Key points: • 4% of Scotland’s population is from a minority ethnic group • minority ethnic groups often have poorer health than the general population, although in Scotland this is not the case for all-cancers and common cancers • ethnic inequalities in health tend to be neglected in policy discussions and omissions in routine data collection may compound this • smoking is one of the major contributors to health inequalities • there are many interlinked factors involved in ethnic health inequalities but lower socio-economic status (which is itself an influence on tobacco use) may be the most important. This specialist briefing is aimed at professionals and policy makers. It provides a short overview of the evidence surrounding tobacco use, ethnicity and health. Scotland’s minority ethnic population is low (4%1). Minority ethnic populations are generally characterised as being disproportionately affected by death and disease2, although the Scottish Health and Ethnicity Linkage Cohort Study3 suggests that for all-cancers and the common cancers this is not so. What is certain is that ethnic inequalities in health tend to be neglected in policy discussions4. Smoking is the main preventable lifestyle factor, particularly for cancer, respiratory and cardiovascular diseases5, and the National Institute for Health and Clinical Excellence6 has suggested that reducing tobacco consumption among minority groups would reduce health inequalities more than any other measure. The Medical Research Council at the University of Glasgow has noted that ethnic minorities are often under-represented in research7, although successful engagement can be achieved using culturally appropriate strategies8. Similarly there are deficits in data collection9 although The Scottish Health and Ethnicity Linkage Study10 has demonstrated that national cancer statistics can be obtained by ethnic group and called for its methods to be applied wherever a population census or database records ethnic group. Tobacco use, ethnicity and health June 2014 Ethnic group demographics Population estimates by ethnic group from Scotland's 2011 Census11: • the size of the minority ethnic population in 2011 was just over 200,000 or 4% of the total population of Scotland • the Asian population was the largest minority ethnic group (3% of the total population or 141,000 people) • just over 1% (1.2% or 61,000) of the population recorded their ethnic group as White: Polish. The cities of Edinburgh and Aberdeen had the highest proportions at 3% of their total population • in Glasgow City, 12% of the population were from a minority ethnic group, in City of Edinburgh and Aberdeen City it was 8% and Dundee City it was 6%12. % of total % of minority ethnic 2011 base population population(rounded estimate) African 0.6 14 30,000 Asian/Asian Scottish/Asian British 2.7 67 141,000 Caribbean or Black 0.1 3 7,000 Mixed/Multiple ethnic groups 0.4 9 20,000 Other ethnic group 0.3 7 14,000 White 96.0 n/a 5,084,000 All Minority Ethnic Population 4.0 100 211,000 All Population 100 n/a 5,295,000 Migrants According to the Migration Observatory at the University of Oxford13, in 2004 the number of non-UK born residents was estimated to be 204,000 and the number of non-British nationals was 127,000. Both of these numbers have increased continuously over time. In 2012 there were 375,000 non-UK born people resident in Scotland (7.2%) and 285,000 non-British nationals. This total represents an increase of 84% in the non-UK born population and an increase of 124% in the non-British population since 2004. An estimated 5.5% of Scotland residents in 2012 were non-British nationals which also represents an increase from the 2004 value (2.5%). The share of Scotland’s population which is non-UK born is smaller than that of the UK as a whole (12% in 2012). Likewise, the share of Scotland’s population with non-British nationality is smaller than that of the UK (7.8%). Tobacco use, ethnicity and health June 2014 Gypsy travellers The term 'Gypsy/Traveller' refers to distinct groups - such as Romany Gypsies, Scottish and Irish Travellers - who regard the travelling lifestyle as being part of their ethnic identity. Scottish Government figures from July 200814 recorded an estimated 744 households living on sites and encampments in Scotland. This is estimated to represent a population of around 2,455 people. Research based on the English and Welsh population15 suggests that rates of smoking are very high in the Gypsy or Irish Traveller group, 49% and 46% for males and females respectively. Smoking prevalence Although the Race Relations (Amendment) Act 2000 and NHS policy require health services to show that they are promoting racial equality and reducing ethnic inequalities, routine data sources in Scotland do not include the information needed to (a) measure health inequalities, (b) assess service use, and (c) demonstrate compliance with policy and legislation16. According to the Scottish Health Survey17, in 2012 one in four adults (aged 16 and above) in Scotland was a current cigarette smoker. No difference was found between men and women (25% and 24% respectively), although smoking did vary by age, with the highest rate among adults aged 25 to 44 (29%). A report using four years (2008-2011) of the Scottish Health Survey18 reported on prevalence by ethnic group. However, even combining four years of survey data, the number of respondents in these ethnic groups is still too small to estimate smoking prevalence reliably. The report does note though that respondents from ‘Pakistani’ and ‘Asian, Other’ ethnicities were less likely to smoke than the national average (13% and 9% respectively, compared to the average of 25%). Older survey work19 conducted in England noted that there are also large gender differences in smoking within some ethnic groups (eg smoking in Pakistani and Indian women was very low at around 5%, while the rate among men was more similar to the general population) - some of these differences also may be true for Scotland. A study of minority ethnic tobacco use in Glasgow confirmed higher rates of smoking, especially among Pakistani respondents, young people and women20. A 2007 study21 of the smoking behaviours of UK resident Bangladeshi men showed that smoking initiation and use is linked to gender, age, religion and tradition, and that three cheaper alternative tobacco types were also used: illicit, roll-ups and traditional chewing tobacco in paan (chewing tobacco mixed with areca (betel) nut rolled in a betel leaf). Smoking behaviour was also linked to a reported isolation and exclusion from current tobacco control initiatives. Tobacco use, ethnicity and health June 2014 Ethnicity and health inequalities Mortality data have identified the following kinds of differences in health across ethnic groups22: • generally poorer health among non-White minorities, with Bangladeshi people having the poorest health, followed by Pakistani, Black Caribbean , Indian and Chinese people • high, but variable, rates of diabetes across all non-White groups • high rates of heart disease among South Asian people, but particularly among Bangladeshi and Pakistani people. The risk of cardiovascular disease varies across ethnic groups within the UK with the lowest rates in the Chinese-born and the highest in the South Asian-born groups23. It has been apparent since the 1980s that UK South Asians have a higher risk of developing cardiovascular disease and diabetes and that African-origin populations have a higher risk of developing cerebrovascular diseases (causing strokes) and diabetes24. Scotland is noted for its internationally high cardiovascular disease rates, and Pakistanis in Scotland have the highest incidence of acute myocardial infarction25, suggesting a need for a clinical care and policy focus on reducing incidence through more aggressive prevention. A study26 which used cross-sectional data from the 2007 Citizenship Survey linked to the 2001 UK census notes that ‘[t]here is strong evidence that the economically poorer areas in which ethnic minority people on average live, negatively impact on health over and above individual socio-economic markers.’ There are many interlinked factors involved in ethnic health inequalities but lower socio-economic status (which is itself an influence on tobacco use) may be the most important27. Other tobacco products The World Health Organization has predicted that tobacco use will kill one billion people in the 21st century28, and although most will be killed by cigarettes it is nevertheless important to recognise that tobacco can be consumed in many other forms, all of them harmful. Chewed tobacco products are associated with an increased risk of mouth and throat cancers among users29. People in the Indian, Pakistani and Bangladeshi communities are the most likely to use chewed tobacco products and the tobacco is usually mixed with betel nut which is itself a mood-altering stimulant, possibly carcinogenic and potentially dependence forming30. The UK is the number one importing country for paan outside of Asia, with imports having doubled since the early 80's31. In some parts of the Asian community young children start using sweetened betel nut products but begin to add tobacco later in their adolescence32. A 2010 study33 on the accessibility of chewing tobacco products in England found that less than half (48%) of chewing tobacco purchased had any form of health warning, while only 15% of products complied with the current legislation of health warnings for smokeless tobacco products, suggesting a need to challenge retailers selling smokeless Tobacco use, ethnicity and health June 2014 tobacco to ensure they comply with the current UK and EU labelling and health warning regulations. There is a lack of knowledge and understanding about the health risks of chewing tobacco in South Asian communities34 but the links between smoking and lung cancer are recognised.